|Year : 2021 | Volume
| Issue : 3 | Page : 375-379
Oculo-orbital involvement in craniofacial injuries following road traffic accidents
Adyasha Dash, Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, Sikshya O Anusandhan (Deemed to be) University, Bhubaneswar, Odisha, India
|Date of Submission||08-Jun-2021|
|Date of Acceptance||27-Jun-2021|
|Date of Web Publication||30-Sep-2021|
Dr. Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, Sikshya O Anusandhan (Deemed to be) University, 8-Kalinga Nagar, Bhubaneswar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Craniofacial injury is of common occurrence following road traffic accidents (RTAs). It often leads to serious disabilities, including significant damage to the visual system.
AIM: This study aims to evaluate different ocular and orbital manifestations in patients of craniofacial injury following RTA and estimate the incidence of craniofacial injuries following RTA.
MATERIALS AND METHODS: All patients with craniofacial injuries following RTA between August 2014 and August 2016 were included in the study. All patients underwent comprehensive ophthalmic evaluation. Imaging studies were done wherever indicated.
RESULTS: Out of 840 cases of RTA, 77 cases presented with craniofacial injuries. Incidence of craniofacial injuries was 9.16%. Of the 77 patients, 65 (85%) were male and 12 (15%) were female. Average age was 31.15 ± 12.57 years. The most common age group affected was 21–30 years age group with 34 (44%) cases. Soft tissue injury to globe and adnexa was the most common injury seen in 69 (89.61%) cases. Injury to the orbital wall was present in 33 (42.85%) cases. The sphenoid bone in 28 (36.36%) cases was most commonly involved followed by frontal bone in 24 (31.16%) cases. Subconjunctival hemorrhage was the most common ocular finding noted on anterior segment examination in 51 (66.23%) cases. Commotio retinae was the most common retinal finding seen in 5 (6.49%) cases.
CONCLUSION: Several human and environmental risk factors are associated with increased risk of RTA. If controlled properly, it can lead to reduction in mortality and morbidity associated with RTA.
Keywords: Craniofacial, ocular, orbital, road traffic accidents
|How to cite this article:|
Dash A, Panigrahi PK. Oculo-orbital involvement in craniofacial injuries following road traffic accidents. Indian J Health Sci Biomed Res 2021;14:375-9
|How to cite this URL:|
Dash A, Panigrahi PK. Oculo-orbital involvement in craniofacial injuries following road traffic accidents. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Dec 8];14:375-9. Available from: https://www.ijournalhs.org/text.asp?2021/14/3/375/327247
| Introduction|| |
Craniofacial injury, a term which actually means cranio-cerebral damage and injury to face, has been recognized since long. Craniofacial injury is of common occurrence among road traffic accident (RTA) victims. It can lead to several disabilities including damage to the visual system. Although the eyes represent only 0.1% of the total body surface and 0.27% of the anterior body surface, their significance to individuals and the society is disproportionally higher. The role of ocular injuries secondary to craniofacial trauma in the causation of blindness continues to be of immense public health problem. The immediate impact of craniofacial injury threatening other vital organs is so compelling that damage to the visual system is most likely to be ignored.
The anatomical location of orbits and the globe are vulnerable to various alterations due to craniofacial trauma. The incidence of ocular injuries varies from 0.8% to 67%. The severity of injuries can vary from a simple subconjunctival hemorrhage to devastating conditions causing blindness such as optic neuropathy and globe rupture. Orbital floor fractures have been associated with 40% prevalence of ophthalmic complications. Nasal fractures and zygomatic fractures are most common craniofacial injuries leading to decreased visual acuity due to destruction of integrity of orbital skeleton., Other ocular manifestations such as diplopia, exophthalmos, hyphema, vitreous hemorrhage, retinal detachment, retinal hemorrhage, choroidal rupture, traumatic mydriasis, and commotio retinae may also occur depending on varying degrees of involvement.,
An injury to the eye or its surrounding tissues is the most common cause for attendance at an eye hospital emergency department. This study was done to evaluate different ocular and orbital manifestations in patients of craniofacial injury following RTA and determine the incidence of craniofacial injuries following RTA.
| Materials and Methods|| |
The present study was a cross-sectional, observational, institution-based clinical study carried out at the Department of Ophthalmology of a tertiary referral medical college hospital from August 2014 to August 2016. The study adhered to the basic tenets of Declaration of Helsinki. All patients provided informed consent before entering into the study. Institutional ethical committee clearance was obtained before starting the study. Ethical clearance was obtained from Institutional ethics committee of Institute of Medical Sciences and Sum Hospital with reference number IMS/IEC/94/2015 dated 16/1/2015. This study, conducted over a period of 2 years, included 840 cases of RTA, of which 77 cases presented with craniofacial injuries.
Cases of RTA with craniofacial injuries presenting to the emergency and ophthalmology outpatient department (OPD) of the hospital were included. Patients with RTA but no craniofacial injuries and patients not willing to provide informed consent were excluded from the study. An extensive clinical history was obtained from each patient. Information regarding the type of vehicular accident, time, location and usage of helmet were noted. History of any past RTA, ocular and nonocular surgery was obtained. Symptoms and signs following RTA were recorded. Comprehensive ophthalmic evaluation was done in each patient. Visual acuity assessment was done using Snellen's chart. Initial torch light examination was done followed by more detailed examination of the anterior segment using slit lamp. Intraocular pressure (IOP) was measured using Goldmann's applanation tonometer and noncontact tonometer. In a few cases, it was not possible to measure the IOP. Wherever possible, dilated posterior segment examination was done using indirect ophthalmoscope.
Plain X-ray of skull in anteroposterior, lateral and Water's view were obtained wherever necessary. B-scan ultrasonography was done in cases with significant media opacities precluding the view of fundus. Computed tomography and magnetic resonance imaging scan of brain and orbits were done in cases who could afford the investigation. Depending on the presentation, patients were subjected to detailed examination by ENT surgeon, neurosurgeon, maxillofacial surgeon, and general physician. Patients were mainly managed at casualty and OPD level, with some patients admitted for further management and specialized care. Patients were followed up at regular intervals throughout the course of admission in the hospital.
Data were entered into Microsoft excel sheet. Data have been represented in the form of mean, absolute numbers and percentage wherever appropriate. Statistical analysis was done wherever appropriate.
| Results|| |
A total of 840 cases of RTA presented to the institution during the study period of 2 years. Of 840 cases, 77 patients presented with craniofacial injuries. The incidence of craniofacial injury was 9.16%. Of the 77 patients, 65 (85%) were male and 12 (15%) were female. Average age was 31.15 ± 12.57 years. The highest incidence was noted in the 21–30 years age group with 34 (44%) cases. Least incidence was noted in the 1–10 years group with 2 (3%) cases. The right eye was involved in 43 (56%) and left eye in 23 (30%) cases. Bilateral involvement was noted in 11 (14%) cases. Fifty-four (71%) cases were 2-wheeler related accidents and 23 (29%) cases where 4-wheeler-related accidents. Salient demographic characteristics are shown in [Table 1].
Craniofacial injuries were seen in 46 (59.14%) cases. Thirteen (16.88%) and 18 (23.37%) patients had only cranial and facial injuries respectively. Soft tissue injury to globe and adnexa was the most common injury seen in 69 (89.61%) cases. Injury to the orbital wall was present in 33 (42.85%) cases. Six (7.79%) patients had neuro-ophthalmic injuries. Facial abrasion was the most common external soft tissue injury noted in 44 (57.14%) cases. This was followed by laceration and avulsion in 20 (25.77%) and 13 (16.88%) cases, respectively.
Out of total cases of 77, bony orbit injury was seen in 33 (42.85%) cases. Out of all bony orbit injury, multiple wall fractures were most commonly seen in 16 (20.77%) cases and fracture of medial wall was the least common seen in 2 (2.59%) cases. Out of all cases with bony orbit injury, multiple bone or more than 3 bones was most commonly seen in 14 (42.42%) cases and single bone involvement was the least common seen in 3 (9.09%) cases. The sphenoid bone in 28 (36.36%) cases was most commonly involved followed by frontal bone in 24 (31.16%) cases. Maxillary, zygomatic, ethmoid, lacrimal, and palatine bone involvement were seen in 19 (24.67%), 20 (25.97%), 13 (16.88%), 13 (16.88%), and 13 (16.88%) cases, respectively [Table 2].
Lid laceration was seen in 16 (20.77%) cases. Periorbital edema was noted in 44 (54.14%) cases. Subconjunctival hemorrhage was the most common ocular finding noted on anterior segment examination in 51 (66.23%) cases. This was followed by traumatic mydriasis and traumatic cataract seen in 6 (7.79%) and 5 (6.49%) cases, respectively. Posterior segment findings were seen in 11 (14.28%) cases. Commotio retinae were the most common retinal finding seen in 5 (6.49%) cases. There were 2 (2.59%) and 1 (1.29%) case of vitreous hemorrhage and choroidal detachment, respectively. There were 3 (3.89%) each case of optic nerve and oculomotor nerve involvement [Table 3]. Intracranial hemorrhage was noted on neuroimaging in 13 patients. Subdural hemorrhage was most commonly seen in 6 (16.88%) patients. Extradural and subarachnoid hemorrhage were seen in 4 (5.19%) and 3 (3.89%) cases, respectively.
| Discussion|| |
Ocular trauma is the cause of one-third of monocular blindness in developing countries. It is significant as it causes physical deformity, social and psychological disability. The reason for high frequency of motor vehicle accidents is due to inadequate road safety awareness, violation of speed limits, old vehicles without security features such as anti-burst locks and energy absorbing equipment, failure to put seat belts or helmets, entrance into opposite traffic way, breach of the highway rules or driving under influence of alcohol. In the present study, none of the patients were wearing the safety seat belt and none of the two-wheeler accident victims had used helmets during the accident period. Most of the accidents were due to collision of one vehicle with another, often in head-on impact, overtaking on one-way routes, or at road traffic crossings.
The present study included 77 patients of RTA who presented with craniofacial injuries. The incidence of craniofacial injuries in this study was found to be 9.16/100 RTA. Our study had a higher male preponderance with 85% involvement as compared to females with 15% involvement. This is similar as compared to the study conducted by Raju NS who reported a male incidence of 82.5% in their study. Higher involvement of males as compared to females can be explained by males being more commonly involved in outdoor activities. Men are more likely to engage in risk taking behaviors which put them at a higher risk of head injury., Majority of the cases in the study belonged to the 21–30 years of age group with 34 (44%) cases followed by 31–40 years' group with 22 (28%) cases. This finding is similar to the findings in other studies by Kulkarni et al. who reported young adult males (21–30) years being more vulnerable to RTA. This result may be due to fact that young people are relatively more energetic and involved in activities and also this age group is frequently careless in following traffic rules. Furthermore, individuals of this age group were either students or prime bread earners of the family and thus remained outdoors during most of the day. Unilateral involvement with right eye 43 (56%) was more common than left eye 23 (31%). The present study was consistent with findings of Shtewi et al. who observed that right eye was involved in 116 (42%) cases which was nearly similar to the present study. This owed mainly because of Indian traffic rules, where the driver keeps to the left.
Das et al., in their study, on pattern of craniofacial injuries in fatal RTA have reported facial abrasions to be the most common form of external soft tissue injury in the craniofacial region with 55.1% cases. Abrasions as a whole constituted the major injury type on nose, mouth and face with a total number of 44 (57.14%) cases in our study. Bony orbital wall injuries were seen in 33 (42.85%) of our cases. Multiple wall involvement was most commonly seen in our study. This was followed by fracture roof 7 (9.09%), lateral wall 5 (6.49%), floor fracture 3 (3.89%), and medial wall 2 (2.59%) cases. Kamath et al. in their study reported infraorbital rim fracture in 22 cases (43.13%), to be the most common followed by floor fracture seen in 10 cases and roof fracture was least common seen in only 1 case. Pakalapati et al. have reported highest number in case of fractures involving roof of orbit in 42.1% cases followed by multiple fractures in 21.1% cases. This was just contrary to the present study which showed a higher incidence of multiple wall fractures followed by roof fracture. In the present study, sphenoid bone 28 (84.84%) was more commonly involved in craniofacial injuries out of all cases of bony orbit injury detected on radioimaging. This was followed by frontal bone fracture 24 (72.72%), zygomatic 20 (60.60%), maxillary 19 (57.577), and ethmoid, lacrimal and palatine in 13 (39.39%) cases, respectively. This finding is inconsistent from the studies done by Holt et al. and Muralidhar et al. who reported frontal bone as the most common bone being involved. MacKinnon et al. observed zygomatic bone as the most common bone being involved in their study in 24% cases. The reason of involvement of sphenoid bone more frequently in the present study may be due to the fact that it partakes formation of three walls of bony orbit, i.e., roof, medial wall and lateral wall.
The most common ocular finding in our study was subconjunctival hemorrhage noted in 51 (66.23%) cases. They varied from small petechiae to large extravasations. In severe sub-conjunctival hemorrhage, posterior limit could not be made out. In anterior segment, traumatic mydriasis 6 (7.79%), traumatic cataract 5 (6.49%), corneal tear 2 (2.59%), corneal rupture 2 (2.59%) followed by corneal foreign body and iris prolapse 2 (2.59%) along with iris sphincter tear in 1 (1.29%) case were observed respectively. In posterior segment, commotio retinae 5 (6.49%), optic neuropathy 3 (3.89%), vitreous hemorrhage in 2 (2.59%) and choroidal detachment in 1 (1.29%) case were observed, respectively. These findings are very similar to other studies which report that soft tissue injuries are very commonly found in comparison to bony and neuro-ophthalmic findings. Of all cases with craniofacial injury, 6 (7.79%) cases presented with neuro-ophthalmic abnormalities. Traumatic optic neuropathy and occulomotor nerve palsy were each seen in 3 (3.86%) cases, respectively. Out of all cases with neuroimaging abnormalities, 13 (16.88%) cases presented with intracranial hemorrhages. Out of all cases of intracranial hemorrhages, subdural hemorrhage 6 (7.79%) was found to be the most common followed by subarachnoid hemorrhage 4 (5.19%) and extradural hemorrhage 3 (3.89%). This finding was similar to the study done by Das et al. and Menon et al. who even reported subdural hemorrhage to be the commonest intracranial hemorrhage followed by subarachnoid hemorrhage. This was contrary to the study done by Chandra et al. who reported subarachnoid hemorrhage as the most common type (66.9%), followed by subdural hemorrhage (58.2%) and extradural hemorrhage (14.2%).
The small sample size of the study is one of the drawbacks of the study. Another drawback is not studying the final visual and anatomical outcomes of the individual cases. In the present study, maximum examination was done in the initial hospital stay or first visit to the ophthalmology department. Follow-up examination was minimal in most of the cases.
| Conclusion|| |
The present study reveals that soft tissue injuries to globe and adnexa like subconjunctival hemorrhage, periorbital edema and ecchymosis are most common ocular manifestations in craniofacial injuries. Bony orbit injuries were less commonly found, most common type being multiple wall fracture. Neuro-ophthalmic manifestations were even less commonly found. Most of the injuries involved the ocular adnexa, which while causing certain degree of cosmetic disfigurement did not lead to any permanent visual sequelae. The people of most active and productive age groups are involved in RTA, which leads to cosmetic disfigurement and serious economic loss to the community. Several human and environmental risk factors are associated with increased risk of RTA. If controlled properly, it can lead to reduction in mortality and morbidity associated with RTA.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]